For Trans Prisoners, Access to Healthcare Remains Abysmal

Some progress has been made, but inmates are still routinely denied access to gender-affirming care and facilities.

Ky Peterson has been waiting to hear back about his parole request for nearly three months. Peterson—a black transgender man who is serving a 20-year sentence in a women's prison for involuntary manslaughter after killing his rapist, which he alleges he did in self-defense—submitted his request in October, along with a post-incarceration plan. According to Pinky Shear, an Atlanta-based community advocate and Ky's partner of three years, it was "extensive." It included medical and financial planning, letters from supporters, proof of housing, a job offer, a plan for continuing education, and a letter from Ky himself detailing all that he accomplished while incarcerated. Despite its thorough nature, the State Board of Pardons and Paroles has yet to render a decision—one that his supporters expected to be delivered by early December at the latest.

In the meantime, Peterson is pushing forward with a different kind of request: top surgery, a procedure involving breast reduction and chest reconstruction that more than one third of all trans men pursue, according to a 2015 survey from the National Center for Transgender Equality (NCTE), one of the nation's leading trans rights advocacy groups. If successful, Ky would become the second trans inmate in the country to receive state-funded gender confirmation surgery while incarcerated, following Shiloh Quine in California earlier this month, and he would set a statewide precedent in Georgia for those who follow. "He's determined to continue to push forward and keep fighting for trans rights in this facility," said Shear.

One could argue that Peterson's case highlights just how much incarcerated trans people's access to gender-affirming medical care has improved over the past few years. At the same time, it underscores how limited that access remains.

Trans people are subject to disproportionate levels of violence and discrimination while they are incarcerated, just as they are in the outside world. The experience of Chelsea Manning provides a notable (if not wholly representative) example—the military whistleblower, whose 35-year prison sentence was commuted by President Obama on Tuesday, has frequently been held in solitary confinement throughout her sentence. While she was allowed to wear gender-affirming clothing and cosmetics and seek speech and hormone therapy, prison officials forced her to adhere to keep her hair short as a security measure. Despite being diagnosed with gender dysphoria in 2010 and coming out as a transgender woman in 2013, Manning has had to take extreme measures—lawsuits, hunger strikes—in order to have her medical needs recognized.

More than a third of incarcerated trans adults report being sexually victimized by staff and other inmates, according to the US Department of Justice's Bureau of Justice Statistics, and 85 percent of queer and trans inmates surveyed in 2015 by the LGBTQ prisoner support network Black and Pink said they have been held in solitary confinement. Trans women—particularly Black, Latinx, multiracial, and Indigenous trans women—were one of the most at-risk groups for "protective" solitary confinement, a measure that has been linked to increases in suicidal ideation and suicide attempts among prisoners.

Attempts to access gender-affirming medical care while incarcerated often leads to difficulties for trans people. And trans inmates are far from the only incarcerated people who are systematically denied access to adequate medical care. Health care access is "abysmal" for all American prisoners, said Jason Lydon, the National Director of Black and Pink. That said, "transgender and gender-nonconforming folks experience greater inequities in all aspects of incarceration," he noted, "and that is true with respect to health care."

The 2015 NCTE survey found that nearly one in four trans people undergoing HRT prior to incarceration were denied access to hormones while in prison. While the survey did not ask respondents to specify whether hormones were withheld as punishment, Lydon said that such measures are not unheard of.

Gender-affirming care is often denied as a result of inexperience with caring for trans patients on the part of prison medical staff; for example, an incarcerated trans person who wishes to receive gender-affirming health care might first need to obtain a psychological evaluation in order to get diagnosed with gender dysphoria. The request process is often "really long" and "unnecessarily bureaucratic," according to Pooja Gehi, the Executive Director of progressive legal advocacy group the National Lawyers Guild, and it inherently privileges the will of the prison staff over the needs of the incarcerated.

Even with an evaluation, it can be hard for trans-identified patients to receive proper medical care. Sometimes, they fail to meet the exact criteria for a gender dysphoria diagnosis as laid out by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, which excludes many gender-nonconforming and nonbinary people from its parameters, and some prisons will deny care on this basis. Even with an evaluation, trans patients are routinely denied HRT if they weren't on hormones before they were incarcerated.Requests for evaluation don't always lead to one, and they certainly do not always lead to a diagnosis necessary for inmates to receive gender-affirming care.

Such care is often cost-prohibitive, as well. Prisons are required to provide medical care to those they house, but, as Black and Pink's 2015 survey noted, that care "does not need to be free." Respondents reported doctor fees as high as $100 per year, a daunting amount for the incarcerated; forty-three percent of those surveyed said that those costs prevented them from receiving the care they needed.

Advocates for incarcerated trans people say that medical staff and those who field psychological evaluations in prisons need to be competent enough in trans issues to handle all patients in their care. And Lydon and Gehi agreed that moving away from a strictly diagnostic model of medical care would better serve incarcerated trans people.

The ability to access gender-affirming clothing and other goods at commissary can go a long way toward improving the mental health of incarcerated trans people. Trans men are often housed in facilities for women, and trans women are often housed in facilities for men. When they're living in an environment that triggers gender dysphoria by its very design, having access to masculine-scented deodorant or bras and women's underwear—as found in Pennsylvania prisons, for example—can "have a huge impact on people's mental health," said Lydon.

Ky Peterson is one of countless incarcerated trans people housed in a facility that does not correspond with their gender identity."He has a really great sense of humor [about being a man housed in a women's prison]," according to Shear. "He tries to make the most of it the best he can." His upbeat attitude is no doubt helped by the gender-affirming medical care, including hormones, he has successfully petitioned for, not to mention the binders (chest-flattening undergarments) and boxer-style underwear (as opposed to more feminine panties) that he is now permitted to wear. But not every incarcerated person, trans or otherwise, is as optimistic as Peterson, nor do they all have such an extensive network of support fighting for them on the outside. Their medical well-being, much less their survival, shouldn't hinge on either.